The Neuropsychiatric Inventory-Clinician rating scale (NPI-C): reliability and validity of a revised assessment of neuropsychiatric symptoms in dementia

BACKGROUND

Neuropsychiatric symptoms (NPS) affect almost all patients with dementia and are a major focus of study and treatment. Accurate assessment of NPS through valid, sensitive and reliable measures is crucial. Although current NPS measures have many strengths, they also have some limitations (e.g. acquisition of data is limited to informants or caregivers as respondents, limited depth of items specific to moderate dementia). Therefore, we developed a revised version of the NPI, known as the NPI-C. The NPI-C includes expanded domains and items, and a clinician-rating methodology. This study evaluated the reliability and convergent validity of the NPI-C at ten international sites (seven languages).

METHODS

Face validity for 78 new items was obtained through a Delphi panel. A total of 128 dyads (caregivers/patients) from three severity categories of dementia (mild = 58, moderate = 49, severe = 21) were interviewed separately by two trained raters using two rating methods: the original NPI interview and a clinician-rated method. Rater 1 also administered four additional, established measures: the Apathy Evaluation Scale, the Brief Psychiatric Rating Scale, the Cohen-Mansfield Agitation Index, and the Cornell Scale for Depression in Dementia. Intraclass correlations were used to determine inter-rater reliability. Pearson correlations between the four relevant NPI-C domains and their corresponding outside measures were used for convergent validity.

RESULTS

Inter-rater reliability was strong for most items. Convergent validity was moderate (apathy and agitation) to strong (hallucinations and delusions; agitation and aberrant vocalization; and depression) for clinician ratings in NPI-C domains.

CONCLUSION

Overall, the NPI-C shows promise as a versatile tool which can accurately measure NPS and which uses a uniform scale system to facilitate data comparisons across studies.

[Primary progressive aphasia: its clinical variability: an analysis of 15 cases]

INTRODUCTION

Primary progressive aphasia (PPA) represents a clinical syndrome linked to multiple degenerative diseases. The diagnosis of PPA is made when language is the only area of salient and progressive dysfunction for at least the first two years of the disease.

AIM

To evaluate the neuropsychological, neuropsychiatric and language characteristics of the PPA.

PATIENTS AND METHODS

15 patients with PPA underwent language, neuropsychological and neuropsychiatric evaluation, magnetic resonance imaging, computerized tomography and single photon emission computerized tomography.

RESULTS

We observed a clear distinction between the oral expression patterns; the patients were classificated by type of aphasia. The most common sign of PPA was a word finding deficit, also known as anomia. Seven aphasia type Broca, four sensorial transcortical aphasia, two aphasia type Wernicke and two anomic aphasia were found in our patients. Depression, apathy, anxiety and irritability were the most prevalent neuropsychiatric sign.

CONCLUSIONS

PPA is a language-based syndrome, that include fluent (normal articulation, flow and number of words per utterance) and nonfluent form of aphasia. It has been considered a cognitive term, however, PPA is associated with high prevalence of psychiatric manifestations. More research it will be necessary to evaluate the prognostic value of them. The slow and progressive deterioration of language provides an interesting model to understand the mechanisms and biological bases involved in the linguistic process.

[Visual art, creativity and dementia]

BACKGROUND

Visual art is an expression of neurological function and how it organizes and interprets perception. The art is predominantly in the right hemisphere, in contrast, the left side, have inhibitory effects on artistic expression. In normal subjects, inhibitory and excitatory mechanisms could interact in a complex harmony, reflecting a paradoxical functional facilitation. Brain diseases such as dementia could change this harmony and then, alter the artistic abilities.

OBJECTIVE

Evaluate the art expression in the degenerative diseases.

PATIENTS AND METHODS

Artistic abilities of 3 painters with degenerative diseases were assessment.

RESULTS

Patient 1: A 83 - year old right handed female, diagnosis: Alzheimer's disease. Artistic description: low productivity, simplified versions of earlier and alteration of the visuospatial organization. Patient 2: A 78-year-old right handed female, diagnosis: Primary Progressive Aphasia (PPA); Artistic description: oversimplified drawings which maintaining overall spatial organization, without impair artistic skills. Patient 3: A 68 year-old right handed woman, diagnosis: Fronto-Temporal Dementia (FTD). Artistic description: Increased artistic activity, originality, freedom, utilization of intense colours with perseverative and repetitive copying of similar paintings of her own work.

CONCLUSIONS

Visual art in Alzheimer's disease is a consequence of visuospatial and constructive disabilities. In contrast, the conservation of this cognitive functions and left asymmetrical involved, in FTD and PPA respectively, suggest artistic preservation, independently of the language injury. The disproportionate functional prevalence of the right over the left could lead to a release of novelty - seeking in art and can contribute to emergent creativity. These observations suggest an organization for art in the brain and proposed bases for further investigations in dementias.

[Relation between patient's subjective complaints and family reports in patients with Alzheimer's type dementia]

INTRODUCTION

Reduced ability to remember facts and events of everyday life is a common complaint in the elderly and is also the first sign of Alzheimer's disease (AD). The present research was designed to study the interrelationship between severity of memory complaints (MC), informant report, and performance in memory tests.

MATERIAL AND METHODS

Seventy three (73) patients (41 age associated memory impairment (AAMI), and 32 Alzheimer's disease) and 30 normal controls were studied using the Subjective Memory Questionnaire (modified version), an objective memory battery and the Hamilton depression scale.

RESULTS

Age Associated Memory Impairment subjects reported more severe MC (p< 0.001). No relationship was found between severity of MC and age, sex or educational level. Patient's MC didn't correlate with objective memory battery. A strong correlation was found with Hamilton depression score. Caregiver memory reports correlated with objective memory performances.

CONCLUSION

Depressive features in AAMI and anosognosia in dementia patients would explain these results. These data suggest that informant report is the best predictor of patient's memory performance.

An open-label trial of sertraline for the treatment of major depression in primary care

Major depression is one of the most common medical disorders seen in primary care practice. Management frequently fails to meet recommended standards of treatment. For example, only a minority of patients are treated with antidepressants. The goals of this study were to establish the safety and effectiveness in the real world of a protocol-based pharmacological intervention administered by primary care physicians trained by psychiatrists. This was a naturalistic, open, 8-week, noncomparative, multicenter study of sertraline, 50-100 mg, in the treatment of 469 patients with mild-to-moderate major depression seen in primary care office settings. Effectiveness was assessed using the Hamilton Depression Rating Scale. The mean value of the HDRS declined steadily from 25.4 at baseline to 8.5 at day 56 (p < 0.0001). Fifty-two percent of patients achieved a full remission (HDRS <10 on day 56) and 70% had a positive response (50% reduction in HDRS scores). Only 26% had side effects, most of them mild. Major depression can be successfully diagnosed and treated by primary care physicians when adequately trained and supported by psychiatrists.

Major depression and its response to sertraline in primary care vs. psychiatric office practice patients. Results of an open-label trial in Argentina

Great strides have been achieved in recent years in the detection and treatment of major depressive disorder (MDD) in primary care settings. Little is known about the types or patients with MDD seen in primary care as compared with those seen in psychiatric office practice. Few studies have compared clinical outcomes after treatment with antidepressants in these two settings. In Argentina, the authors conducted an open-label treatment study of MDD patients in primary care (n = 469) and psychiatric office practice (n = 299). The patients were compared on baseline sociodemographic and clinical variables. These same patients were treated with sertraline 50-100 mg per day for 8 weeks. At baseline, the patients in psychiatric office practice were younger, more likely to abuse alcohol, less likely to have comorbid medical disorders, and more likely to have failed a prior treatment for depression during the current episode. The two groups did not differ significantly on depression severity or in depressive symptom profile on the Hamilton Depression Rating Scale (Ham-D). After 8 weeks of treatment, mean Ham-D scores were reduced comparably in both groups, from about 25 to about 10. Rates of adverse events were 14%-29%, depending on the follow-up interval. Adherence with treatment was high in both groups (over 95%). The patients in primary care and psychiatry office practice are similar in several ways. Significant reductions in depressive symptoms are possible in both settings, in large numbers of patients, by using doses of sertraline in the 50-100 mg range.

[Differential cognitive profiles of fronto-temporal dementia and Alzheimer's disease]

INTRODUCTION AND OBJECTIVE

When the clinical picture consists of prominent cognitive impairments (e.g. amnesia) with relatively mild behavioral symptoms, it can be very difficult to distinguish frontal lobe dementia (FLD) from Alzheimer disease (AD). However, these conditions may have distinct cognitive profiles that could be detected by means of neuropsychological testing. The objective was to examine the early differential cognitive feature between FLD and AD.

PATIENTS AND METHODS

Twelve patients with FLD, 20 patients with AD, and 20 normal subjects matched for age and educational level were evaluated with the Folstein Mini Mental State Examination, the Signoret Memory Battery, the Boston Naming Test, Verbal Fluency (FAS), the Wechsler Adult Intelligence Scale, and the Trail Making Test. The FLD patients met the Lund and Manchester criteria, and the AD patients met the National Institute of Neurological Disorders and Stroke-Alzheimer Disease and Related Disorders Association (NINDS-ADRDA) criteria for clinically probable AD.

RESULTS

FLD and AD patients were matched for the severity of dementia using the Global Deterioration Scale (3.8 +/- 0.3 versus 3.9 +/- 0.5 respectively). Mean Z scores were calculated in order to facilitate the comparison between the neuropsychological profiles obtained. FLD patients scored significantly better than AD patients in memory test, calculation, visuospatial abilities, and the naming test. AD patients performed better on executive tasks.

CONCLUSION

These findings suggest that neuropsychological examination may be useful in differential diagnosis between FLD and AD